Provider Demographics
NPI:1336579085
Name:SUNRISE PHYSICAL THERAPY, LLC
Entity Type:Organization
Organization Name:SUNRISE PHYSICAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:S
Authorized Official - Last Name:STOCKWELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:PT
Authorized Official - Phone:970-749-5308
Mailing Address - Street 1:32 FIR CT
Mailing Address - Street 2:
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-7594
Mailing Address - Country:US
Mailing Address - Phone:970-259-8851
Mailing Address - Fax:877-460-5666
Practice Address - Street 1:100 JENKINS RANCH RD
Practice Address - Street 2:SUITE E5
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-9474
Practice Address - Country:US
Practice Address - Phone:970-259-8851
Practice Address - Fax:877-460-5666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-16
Last Update Date:2013-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2925261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP63174Medicare UPIN